Provider Demographics
NPI:1609060185
Name:MOMJIAN, MANUEL P (MD)
Entity Type:Individual
Prefix:DR
First Name:MANUEL
Middle Name:P
Last Name:MOMJIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1000 N CENTRAL AVE
Mailing Address - Street 2:STE 140
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91202-3687
Mailing Address - Country:US
Mailing Address - Phone:818-662-7000
Mailing Address - Fax:818-662-7131
Practice Address - Street 1:946 N BRAND BLVD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91202-2905
Practice Address - Country:US
Practice Address - Phone:818-662-7000
Practice Address - Fax:818-662-7131
Is Sole Proprietor?:No
Enumeration Date:2007-08-28
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA98448207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABF6782Medicare UPIN